Basic Information
| Provider Information | |||||||||
| NPI: | 1184604928 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOURQUE | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OPTOMETRIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6446 LBJ FWY | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752406407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729602020 | ||||||||
| FaxNumber: | 9729602063 | ||||||||
| Practice Location | |||||||||
| Address1: | 6446 LBJ FWY | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752406407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729602020 | ||||||||
| FaxNumber: | 9729602063 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2006 | ||||||||
| LastUpdateDate: | 12/03/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 5376T | TX | Y | Eye and Vision Services Providers | Optometrist | 152W00000X | 1234 | LA | N | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 80502Q | 01 | TX | BCBS | OTHER |